Core Competencies for End of 3rd Year Psychiatry Training
By the end of third year psychiatry training, you must master comprehensive psychiatric evaluation, evidence-based pharmacotherapy including clozapine for treatment-resistant cases, suicide and violence risk assessment, and the ability to formulate complex cases integrating biological, psychological, and social factors. 1
Psychiatric Evaluation Mastery
Essential Assessment Components
Conduct thorough psychiatric evaluations that identify the reason for presentation, patient goals and treatment preferences, comprehensive psychiatric symptom review including trauma history, substance use assessment (tobacco, alcohol, drugs), complete psychiatric treatment history, physical health status, psychosocial and cultural factors, and detailed mental status examination with cognitive assessment 1, 2
Perform systematic mental status examinations documenting general appearance and nutritional status, coordination and gait, involuntary movements or abnormalities of motor tone, sight and hearing deficits, speech fluency and articulation (rate, rhythm, volume, pressured speech, poverty of speech), current mood state and anxiety level, hopelessness, thought content and process (logical flow, tangentiality, circumstantiality, flight of ideas, thought blocking), and perception and cognition (orientation, memory, attention, executive function) 2
Measure vital signs, height, weight, and BMI as baseline physical parameters, and examine skin for stigmata of trauma, self-injury, or drug use 2
Risk Assessment Expertise
Assess suicide risk systematically by evaluating current suicidal ideas (active or passive), suicide plans, past suicide attempts, patient's intended course of action if symptoms worsen, access to suicide methods, possible motivations for suicide, reasons for living, and level of hopelessness 1, 2
Evaluate violence risk by assessing current aggressive or psychotic ideas, thoughts of physical or sexual aggression or homicide, and document estimated risk with factors influencing that risk 1, 2
Document risk estimates clearly including both suicide risk and aggressive behavior risk (including homicide), with specific factors influencing each risk determination 2
Pharmacotherapy Competence
Schizophrenia Treatment
Initiate and manage antipsychotic medications for schizophrenia, starting with FDA-approved agents and monitoring for effectiveness and side effects 1
Recognize treatment-resistant schizophrenia and initiate clozapine therapy, understanding that clozapine is the evidence-based treatment for patients who fail to respond to other antipsychotics 1
Use clozapine for persistent suicide risk in schizophrenia patients when risk remains substantial despite other treatments 1
Consider long-acting injectable antipsychotics for patients who prefer such treatment or have a history of poor or uncertain adherence 1
Manage extrapyramidal side effects by treating acute dystonia with anticholinergic medication, and managing parkinsonism or akathisia by lowering antipsychotic dosage, switching medications, or adding appropriate adjunctive agents 1
Bipolar Disorder Treatment
Prescribe FDA-approved mood stabilizers including lithium (approved for ages 12 and older for acute mania and maintenance), and understand that lithium, aripiprazole, valproate, olanzapine, risperidone, quetiapine, and ziprasidone are approved for acute mania in adults 1, 3
Recognize that olanzapine and lamotrigine are approved for maintenance therapy in adults, and that olanzapine combined with fluoxetine is approved for bipolar depression 1, 3
Exercise caution with antidepressants in bipolar disorder, using them only as adjuncts when patients are also taking at least one mood stabilizer, as antidepressants may destabilize mood or precipitate manic episodes 1
Consider family history of treatment response as it may predict response in offspring, and be aware that pharmacokinetic parameters may vary in different ethnic groups 1
Pediatric Considerations
Complete thorough diagnostic evaluation before initiating medication therapy for pediatric schizophrenia or bipolar I disorder, recognizing that diagnosis can be challenging with variable symptom profiles 1, 3
Consider increased metabolic risks in adolescents including greater potential for weight gain and dyslipidemia compared to adults, which may lead you to consider prescribing other drugs first 1, 3
Integrate medication with comprehensive treatment including psychological, educational, and social interventions as part of the total treatment program 3
Diagnostic Formulation Skills
Differential Diagnosis
Rule out medical causes of psychiatric symptoms including acute intoxication, delirium, CNS lesions, tumors or infections, metabolic disorders, and seizure disorders through thorough physical examination 1
Order appropriate testing based on clinical findings rather than routine laboratory panels, focusing on abnormal vital signs and targeted neurologic, cardiac, and respiratory examination 1, 2
Distinguish psychotic mood disorders from schizophrenia, developmental disorders, organic conditions, and nonpsychotic emotional/behavioral disorders 1
Recognize phases of schizophrenia including prodrome (social isolation, deteriorating function before overt psychosis), acute phase, and maintenance/recovery phases 1
Use of Quantitative Measures
Incorporate standardized rating scales to identify and determine severity of symptoms and functional impairments that may be treatment targets 1, 4
Track symptom changes objectively using standardized measures at follow-up visits 4
Treatment Planning and Documentation
Comprehensive Treatment Plans
Create documented, comprehensive, person-centered treatment plans that include evidence-based nonpharmacological and pharmacological treatments 1
Document rationale for treatment selection including discussion of specific factors that influenced the treatment choice 2
Tailor psychiatric evaluation to unique patient circumstances using clinical judgment to determine which questions are most important for initial assessment 1, 2
Follow-Up Care
Evaluate target symptoms systematically at medication management visits, assessing changes in severity, frequency, and impact on functioning 4
Review medication adherence patterns including missed doses and reasons for non-adherence, and document response to current medications including degree of symptom improvement 4
Assess medication side effects particularly sleep disturbances, appetite changes, weight fluctuations, and sexual dysfunction common to psychiatric medications 4
Screen for drug-drug interactions by reviewing the complete medication list including over-the-counter medications and supplements 4
Evaluate functional status changes in social, occupational, and educational functioning, and assess impact on quality of life 4
Update substance use assessment reviewing current tobacco, alcohol, and other substance use patterns 4
Document new medical diagnoses, hospitalizations, or procedures and changes to non-psychiatric medications 4
Identify new psychosocial stressors and changes in social support, housing, or financial circumstances 4
Critical Clinical Pitfalls to Avoid
Never skip systematic symptom assessment even when patients drive the agenda, as patients may be reluctant to reveal emotional problems due to stigma, leading to missed diagnoses 4
Never assume stable symptoms mean psychosocial assessment is unnecessary, as psychosocial factors predict healthcare utilization and relapse independent of symptom severity 4
Never misinterpret mental status findings without considering education level, language barriers, or cultural factors, and always maintain careful attention to abnormal vital signs and complete neurologic examination 2
Never use psychological testing to diagnose schizophrenia, though intellectual assessment may be indicated when developmental delays are evident 1
Never prescribe olanzapine monotherapy for depressive episodes associated with bipolar I disorder or treatment-resistant depression, as it is not indicated for these conditions 3